Healthcare Provider Details

I. General information

NPI: 1942792312
Provider Name (Legal Business Name): COUNTRY COTTAGE ON MAIN STREET ADULT DAY CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S MAIN ST
BROOKSVILLE FL
34601-3337
US

IV. Provider business mailing address

201 S MAIN ST
BROOKSVILLE FL
34601-3337
US

V. Phone/Fax

Practice location:
  • Phone: 352-433-8100
  • Fax:
Mailing address:
  • Phone: 352-433-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. TERESA M TRENTINO
Title or Position: ADMINISTRATOR
Credential:
Phone: 727-459-1189